Caregivers II

Allegation investigated: Due to neglect, resident developed pressure injuries

Licensing Program Analyst (LPA) Becky Mann met with Jaewon Hong, Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 05/05/2026 to discuss the complaint investigation. The investigation consisted of LPA observations, pertinent record reviews and interviews with staff. The allegation that due to neglect, resident developed pressure injuries. Based on LPA record reviews, Resident #1 (R1) adult briefs were changed every few hours or as needed. LPA was unable to interview R1, they passed away on 07/29/2024. LPA interviewed staff. Staff #1 (S1) stated that R1 had frequent bowel movements and was changed 8 to 9 times daily. Staff #2 (S2) confirmed that R1 did not have any sores upon arrival at the facility on 07/03/2024. S2 became aware of the first sore on July 13th or July 14th. S2 assisted with changing R1 linen, cleaned the wound and administered medication as prescribed. Hospice began about 07/16/2024 and Stage 1 wound was noted. Substantiated Based on evidence obtained during this investigation and information obtained during the Departments investigation on complaint 56-AS-20240807122804, R1 develop pressure injuries due to neglect is Substantiated. A determination that the complaint is substantiated means that the allegation is/are valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Jaewon Hong, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 5, 2026 · control 56-AS-20240719145550

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 5, 2026

87468.2 Additional Personal Rights Residents in Privately Operate Facilities (a) In addition to the rights listed...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient... This requirement was not met as evidenced by: Based on record reviews, observations, and interviews with pertinent individuals, licensee did not comply to ensure R1 was provided with care, supervision, and services required. As a result, R1 sustained pressure injuries while at facility. This violation posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Due to facility closure, there is no Plan of Correction (POC)

Allegation investigated: Questionable death Facility staff did not assist resident with incontinence care as needed Facility staff did not follow hospice care plan Facility staff handled resident in a rough manner Facility staff stole resident's personal items Facility staff did not ensure resident had enough to eat

Licensing Program Analyst (LPA) Becky Mann met with Jaewon Hong, Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 05/05/2026 to discuss the complaint investigation findings. On 08/07/2024, the Department received a complaint with multiple allegations including allegations of Questionable Death. The Department investigation consisted of review of facility and medical records, observations, and interviews with pertinent individuals. Resident #1 (R1) cause of death was Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia. A Kaiser Infectious Disease Specialist who treated R1 said that it cannot be conclusively determined that the bacteria entered R1’s bloodstream through wounds. There are other ways the bacterium could have entered R1 system. In addition, R1’s immune system was severely compromised. This impacted R1 ability to fight off any infections. R1 developed sepsis and died in the hospital on 07/29/2024. Unsubstantiated The allegation that Facility staff did not assist resident with incontinence care as needed. Based on LPA observations and record reviews, Resident #1 (R1) adult briefs were changed every few hours or as needed. Staff #1 (S1) stated that R1 had frequent bowel movements and was changed 8 to 10 times daily. S1 stated that they always clean and dry R1 during adult brief changes. The allegation that Facility staff did not follow hospice care plan. Staff #1 (S1) stated that they did everything the hospice nurse told them to do for R1 diaper changes. This included applying cream to the skin. S1 said that they would always clean and dry R1 during diaper changes. The allegation that Facility staff handled resident in a rough manner. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied handling the resident roughly. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation. The allegation that Facility staff stole resident's personal items. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied stealing resident personal items. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation. The allegation that Facility staff did not ensure resident had enough to eat. LPA was unable to interview Resident #1 (R1); the resident died on 07/29/2024. LPA interviewed staff, and staff denied not ensuring resident with enough food to eat. Staff stated that there was enough food for the residents at the facility. LPA was unable to interview other residents in care due to the facility closing on 04/30/2025. There was no evidence to corroborate the allegation. Based on evidence obtained during this investigation, the allegation above is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Jaewon Hong, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 5, 2026 · control 56-AS-20240807122804

Type of visit: Case Management - Licensee Initiated

On 4/23/2025 at 10:30 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an announced visit to confirm that all of the residents have been relocated in anticipation for the facility's closure. LPA Serrano were granted entrance by the licensee Jumsoo Kim. On 4/03/2025, LPA Serrano was informed that there are no more residents living in the facility. The licensee is initiating this closure. LPA inspected the entire facility which included the bedrooms, bathrooms, dining area, kitchen, and the backyard. There were no residents present, and there were no belongings of residents in the facility. Licensee Jumsoo Kim stated that the reason of the closure is due to licensee’s retirement after 20 years. Licensee Jumsoo Kim submitted the following during the closure plan. 1. Letter to Community Care Licensing Division (CCLD). 2. Names of the three (3) residents (resident roster) and where they were relocated. Jumsoo Kim will surrender the original license to LPA Serrano via mail or deliver to the regional office. The effective date of closure will be 4/30/2025. An exit interview was conducted, where this report, LIC809 was discussed with and provided to Jumsoo Kim.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bernadette Allen met with Jaewon Kim Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 9/30/2024 at 10:15 AM to initiate a Case Management Office Visit. LPA Allen requested that Jaewon Kim come into the office to sign an amended report to make corrections to deficiencies LIC809-D An exit interview was conducted where this report was discussed, and a copy was provided to Jaewon Kim Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Mr. Kilho Kim -Caregiver who granted entry into the facility. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of three (3). LPA Allen observed 1 staff, 2 residents, per Mr. Kim 1 resident was on a walk. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature tested within regulation at 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed three (3) residents files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s). The 3 files provided for review during the visit were not current or incomplete. A citation was issued for not having current/complete files available for the residents in care. LPA attempted to review 3 staff files that were not available for reviewed during the inspection. A citation was issued for not having staff files available for review. Based on the observations made during today’s visit, two deficiencies were cited. An exit interview was conducted, where this report LIC809, LIC809-C, LIC809-D and LIC9132 facility inspection checklist was discussed and provided to Mr. Kim caregiver at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Sep 26, 2024